Go Wide before Closing in: A Safe Approach to Minimally Invasive Hysterectomy for a Large Broad Ligament Leiomyoma

Abstract

<h3>Study Objective</h3> Demonstrate total laparoscopic hysterectomy technique for a large broad ligament leiomyoma. <h3>Design</h3> Surgical video <h3>Setting</h3> Tertiary-care operating room using standard equipment for laparoscopic surgery and four 5 mm trocars, a 30-degree laparoscope, and bipolar sealing device. <h3>Patients or Participants</h3> A 47-year-old female with pelvic pressure, bulkiness and occasional right sided pelvic pain found to have a twenty-centimeter broad ligament leiomyoma. <h3>Interventions</h3> She desired to have a definitive surgical treatment. She underwent total laparoscopic hysterectomy, bilateral salpingectomy, and cystoscopy. <h3>Measurements and Main Results</h3> Although leiomyomas are the most common benign tumors of the female pelvis, broad ligament leiomyomas are rare. Broad ligament is the most common extrauterine site for the occurrence of leiomyoma with the incidence of <1%. Laparoscopy revealed a large pelvic mass extending through the right board ligament and retroperitoneal space consistent with radiographic imaging. The surgery began on the left side by ligating the blood supply to the uterus in the retroperitoneal space, disconnecting the suspensory ligaments of the uterus. On the right side, the round ligament transected and the incision extended parallel to the infundibulopelvic ligament to enter the right retroperitoneum. The uterine artery was ligated at its origin and the mass was carefully enucleated out of lateral pararectal space while preserving the branches of hypogastric nerve. We utilized the colpotomy cup to demarcate our anatomical landmark and complete the hysterectomy. Pathology revealed benign leiomyoma and reported no malignancy in uterus, cervix and bilateral fallopian tubes. <h3>Conclusion</h3> Board ligament leiomyomas may pose significant anatomical distortion and adhesive disease making minimally invasive surgical approach very challenging. Anatomic knowledge is imperative to safely gain access to the retroperitoneal space, ligate the blood supplies at its origin, preserve crucial pelvic nerves and excise these masses without increasing morbidity to the patient.